Stephen Higgins, a behavioural pharmacologist at the University of Vermont, conducted a study in which cocaine addicts had their urine tested for presence of cocaine several times a week, and earned vouchers every time their sample tested drug-free. The payments started at $2.50, and went up by $1.50 for each consecutive time the urine was clean. Long spells without cocaine were clearly the best way to cash in. One positive urine test, though, and the amount of payment crashed back to the baseline.
No actual money left the clinic. Instead, therapists and clients discussed the way in which the vouchers would be spent, plumping for something that was pleasurable to the client, but also in keeping with the changes in lifestyle that the programme's intensive counselling was intended to foster. To help heal family rifts, an addict might splurge on a fancy dinner out with them; to take up neglected hobbies and sports, he or she might buy basketball shoes or time on the courts.
The voucher-therapy results were excellent. 85 per cent of the patients stayed in the programme for 12 weeks, while 65 to 75 per cent stayed for 6 months - and this for an addiction where a 70 per cent drop-out rate at 6 weeks is the norm for treatment programmes. Not only that, but most of the patients 'passed' their urine tests with flying colours for several months at a time. The voucher system was recently retested by Kenzie Preston at the NIDA with a hard-core inner-city group of cocaine addicts, worlds apart from Higgins's study, which involved mainly white addicts in Vermont. Again, the results were glowing.
Perhaps the biggest stumbling block will be the scheme's political palatability. Even if it is the best treatment going, the notion that drug users will be paid for simply obeying the law and keeping off drugs will go down like a ton of bricks in some quarters. The notable exception, perhaps, is addicts who are pregnant. Here, after all, there is the baby's life to consider as well.
Ronith Elk, psychologist at the University of Texas at Houston, is heading one of several efforts to test the voucher method with a group of pregnant addicts. She hopes to get positive results: not only drug-free urine, but - because one of the urine samples must be taken on the day of antenatal classes - women who will take better care of themselves during pregnancy.
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